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Top Ten Obesity Myths

Learning Objectives
1. Describe the top ten myths surrounding obesity
2. Discuss effective strategies for supporting patients with obesity
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Audio Transcript

Introduction: Welcome to Obesity: A Disease, the official Obesity Medicine Association podcast exploring the many facets of the disease of obesity. In this episode we'll be hearing from obesity medicine specialist and OMA clinical education director Dr Nicholas Pennings. Joining him is Dr Angela Golden. Dr Golden is owner and provider of the NP Obesity Treatment Center, as well as being a prolific contributor to the OMA and a speaker at the 2022 Spring Obesity Summit. Today our guests discuss the top 10 myths surrounding obesity. Obesity: A Disease podcast is brought to you by the Obesity Medicine Association, a clinical leader in obesity medicine.

Nicholas Pennings, MD: One of my favorite quotes, apparently wrongly attributed to Mark Twain, is “The problem with science is not what we don't know, but what we know that we know that just ain't so.” I think that applies to so many areas of science, especially medicine. The history of medicine is rich where medical dogma of the day turn out to be false, if not dangerous. Cancer, along with many diseases, was due to an imbalance of the four humors that regulated bodily function, and one of the treatments for this was bloodletting, which would drain the excess blood to help rebalance humors. Seizure disorders were the result of demonic influence resulting in sometimes barbaric treatments like trepanation, where a hole is placed in the skull. Less than 100 years ago, frontal lobotomy was used as a treatment for mental illness. High doses of mercury was once the treatment of choice for syphilis. The treatment of obesity has its own share of myths--laxatives, and purging agents were once used as treatments of choice. The use of thyroid supplements, DNP, and amphetamines, including obetrol which contain a mixture of amphetamine salts, including methamphetamine. The disastrous consequences of which continue to have negative influence on the use of anti-obesity medicines today. “It's all about willpower. You just need to exercise and eat less. If people just had enough willpower, they wouldn't have to take medications or have surgery” are a few of the ongoing pervasive misunderstandings about obesity.

Hi, it's Dr Nick Pennings, chair of Family Medicine, Kimball University School of Osteopathic Medicine and executive director of Clinical Education at the Obesity Medicine Association, and with me today is Angie Golden, DNP, FNP certified FAANP. She's owner and provider of the NP Obesity Treatment Center. Dr Golden is a prolific contributor to the OMA and was certainly very prolific at the last conference that we've had where she also presented at the 2022 Spring Obesity Summit on Top Ten Obesity Myths. Welcome, Angie.

Angela Golden, DNP: Thanks for having me, I'm excited.

Pennings: So I mentioned a number of myths that surround obesity. What would you say is your favorite myth that you like to talk about?

Golden: I think my favorite both for my patients and for other providers is the one you mentioned. The one about it's all about willpower. I think that's the one that needs to be debunked almost first, and when you debunk it, it really helps people understand obesity is a disease, so if I can get people to understand that it's about more than willpower, I usually have convinced them that obesity is a chronic, progressive, relapsing, and treatable disease. So that's my favorite one that I always start with, with my patients.

Pennings: So what are some of the things you say to health care providers to try to debunk that myth that it's all about willpower?

Golden: So I think with health care providers, I really start with the whole concept of that It's a neuroendocrine disorder, that it's about how the brain and the endocrine system, the hormones, the peptides communicate to create this hunger and energy homeostasis. And sometimes I'll even get to the point where I say “I don't have control over my body temperature,” which is about homeostasis. And a big par…the platform of energy homeostasis, and thereby weight, is really about that communication of the hypothalamus with the hormones and peptides that are being produced. And willpower can't override those hormones and those peptides. Yes, there's absolutely the hedonic eating portion, which is about cognitive control, but it's a small portion of what's happening inside the body when we talk about the overall complexity of energy homeostasis. And I think when we do that, we can really start to get them to understand just how complex the system is. And if I get 30 more seconds with them, then I start to talk about all the hormones that are involved like ghrelin and leptin and adiponectin and some of the other peptides that GLP-1s that really start to impact energy homeostasis. And for a lot of people, they kind of like, “Really. I thought it was just a matter of people needed to push away from the table. It was really just willpower.” And I think when we can get to that, it helps, but I think there are lots of ways to go around it and you probably have ways you've used too.

Pennings: I do and I think this is something that really speaks to the need of more obesity education in our health professional schools, so that future clinicians have a better understanding of that, because if you're not taught those things, if you don't have a good understanding of those neural hormonal pathways, you're going to assume that it's a conscious decision-making process that determines how many calories you eat or how many calories you expend. And as you dive into the details, you realize that that's not true, that it's really much more driven by those internal signals, and so that's how do you explain it to other health care providers. How do you explain it to your patients?

Golden: So for my patients, I really still come back to helping them see…and I usually use a model of the brain so that I can show them where in the brain this homeostatic control occurs. Because when they can see that it's deep in the brain, it's not in those areas where they think of as where their thoughts occur. It often is almost like a light bulb coming on for them. And I talk about it, even being that it's more than just hunger, that even there are hormones that can tell us whether or not to move more. So it really can come down to how tightly controlled our body can be for so many different functions, and that really our energy or weight can be that tightly controlled. The difference, of course, is that we do have this other type of control, and people put so much weight on that part of the control they don't recognize this physiology piece. So I really just show them pictures of the brain and then the pancreas and the intestines and how those are sending signals to the brain. And when they see that they realize they don't have control over those signals. And they start to really understand how it's more than just what they're thinking about. [crosstalk]. And that can be so powerful. The picture is 1000 words.

Pennings: That is, that is very helpful, and I think a powerful way of being able to convey that. Then patients feel like also that it is up to them and it's all about their decision making that is going to determine their success or failure. And not realizing that no matter what their weight is, whether they weigh 150, 250, 350 pounds, when they calorie restrict they're hungry, and they're going to be hungry.

Golden: I think too and one of the other things I'm sure that you have to talk to your patients all the time about too is one of the other myths, but I think too people don't understand that, as they treat their disease, yes, there is a part of behavior that's part of treatment. So food choices, what foods we select can be used as medicine. So food is medicine. You know, what they pick to eat, so food preparation can absolutely be part of how they treat it, but that's not the same as willpower. And I often have to separate those two things out for them when we talk about willpower, that food preparation is about planning, not about willpower. And when we plan, that's part of treatment. And I think that's another way to help people take away that willpower piece, because I think when you just look at the definition of willpower, the Oxford Dictionary says it's the control exerted to do something or restrain impulses. Well, if we're planning, that's not the same as restraining an impulse. Restraining an impulse is not walking into the candy store and buying the candy. Planning is having the right foods in the house that will treat and give you the healthiest possible food to treat your body. So I think that also helps people really understand the difference between how food can be used to treat disease, which is part of our behavior treatment, and not behavior treatment as…overriding their willpower.

Pennings: One of the things I refer to willpower as is something you need to do, something you don't want to do, and that takes willpower to do something you don't want to do, and that trying to get patients to align their desires with their actions. And when you're aligning your goals with your actions, then it doesn't take willpower. It just takes follow through.

Golden: Yeah, I like that a lot. I'm going to steal that from you and use that on my willpower handout that I have because that's a great way to help people kind of shift their thinking, reframe how they look at what they're doing. That's a great way to do it. I love that.

Pennings: Exactly. So another thing you talked about was…one of the myths is that obesity is a risk factor, not a disease.

Golden: Yeah, so I think that for especially many of our colleagues, they hear a lot about obesity as a risk factor. And it's important for us to get them to understand that obesity causes so many different things. There are obesity-related complications. And to do that, sometimes we have to even back up so far as just to say well, what is a chronic disease? And once we get to the point that they're back to school and remembering what a chronic disease is, it's pretty easy to show them that obesity is a chronic disease. It has structural abnormalities like left ventricular hypertrophy that goes long enough. But we have enlarged adipose tissue. We have 236 obesity-associated conditions, and I think the one that I often find other health care providers hear the best are the 14 obesity-related cancers. Many don't even realize that obesity is impacting the cancer rate in the United States.

And then we have lots of signs and symptoms, one of the things that makes it a chronic disease. Exercise intolerance, insulin resistance, chronic inflammation, which is the underlying pinnings of pathophysiology of the disease. And I think when we get to all of those things, people start to go “Oh.” But I think the piece that brings it home the best is talking about the etiology of the disease, because again, many people think it's about pushing away from the table sooner. And when we talk about etiology as you are well aware and I know you're teaching this not only to your patients, but to all of your residents and your interns and your medical students. It's that etiology that says, absolutely there's genetics, but there's also environmental factors that are probably what turn most genetic susceptibility on. And then there's physiologic factors. You know, I always hate to admit that there's biologic factors which may be what we're causing by giving obesogenic medications.

Pennings: Right, so iatrogenic effects that are occurring and a risk factor can be disease too, right? Hypertension is a risk factor, but it's also a disease [crosstalk]. Diabetes is a risk factor, but it's also a disease, so it does increase risk and it does increase the risk for a number of diseases. But it is a disease unto itself as we understand the pathophysiology of obesity and what the inflammation and other disorders that occur. So another one you mentioned was that surgery is cheating [crosstalk, laughter].

Golden: This is one of my favorites, partially because of what happened on a TV show with obesity is cheating. And obesity is cheating. We know you and I both are very clear that that's very far from the truth. First of all, most people don't want to undergo surgery because they think it's a simple way through. Surgery is never a simple way to something. But on a TV show Blue Bloods, the character had bariatric surgery done and one of the other characters on the show said, oh so you're cheating to lose weight and they were bombarded by letters…CBS was…and they actually reshot a scene so that they could debunk that, and talk about how “no, that wasn't cheating.” It was actually a tool to treat the disease, and I think that that would be like saying cardiac bypass surgery was cheating if you had excess plaque in your coronary arteries. That, “Oh, no, we're just going to treat and prevent more plaque from occurring, but we'll let just let that stay there.” I mean, that's ridiculous. Nobody would think that in cardiology; we would say this is severe disease and it may require the more severe treatment i.e., surgery, and you'd have coronary artery bypass surgery done.

Pennings: As we learn all the metabolic changes that happen as a consequence of surgery, that it's not just restrictive, it's not just malabsorptive, but it's actually producing…reversing some of the physiologic abnormalities that exist in patients with obesity.

Golden: And I think the fascinating part is, it happens almost immediately after surgery, so it can't possibly be from the restriction. Within days after surgery, we see a change in the intestinal hormones. GLP1, peptide tricine changes. So we start to see these very early changes in intestinal hormones. Well that can't be just because of restriction, so we know that surgery is doing a great deal more than that. And we see, of course, the difference in ghrelin, the hunger hormone.

Pennings: Right.

Golden: So, it is a hormonal surgery. And I think that's really important for both our patients to understand and our colleagues.

Pennings: So one of the metrics that's used in judging whether anti-obesity medications are effective or not is whether they achieve a 5% weight loss or more. And we see health benefits at a 5% weight loss, but yet many patients feel like they need to lose a lot more, and one of the myths that you talked about was you need to lose a lot of weight to have any benefit. So how do you explain to patients that just a 5 to 10% weight loss can have significant health benefits?

Golden: So, I do that by asking patients what their goal is outside of this scale. Because I think the first thing we have to do is get away from a number on the scale--because again, a number on the scale doesn't tell us we've gotten rid of the excess adipose tissue, it has a lot more than that, so I really start with what quality-of-life indicators they need. So if they have diabetes, are they trying to improve their hemoglobin A1C? Numbers that we can follow. Are they trying to improve their blood pressure? Maybe they're trying to decrease their medication burden from some of these obesity-associated disorders. And also, do they have maybe osteoarthritis and they want to be able to walk further? So, as soon as I get that piece from them, what they're trying to do beside the number on the scale, then it's pretty easy, because then I can say, “Oh well, with about a 5 to 10% weight loss…” So if they weigh 200 pounds, 10 pounds, “…we can start to see an improvement in your numbers for diabetes or your numbers for your blood pressure.” And they're usually pretty surprised by that. And so I just say, “Let's just start with that first. It doesn't mean we're going to stop there, but let's make that your first goal and see how you feel when we hit that goal, and then we'll go to the next one and see what your next goal might be.”

I try not to set a really long-term goal that has to do with a number. And for most patients, even if they really want to set a long-term goal, I usually work with them on what clothing size they want to be in, versus a number on the scale. Because for most of us, it's really not the number on the scale, it's how we look. And even though I'd like for it to be mostly about their health, for most of us…and I'm a woman living with obesity, so I understand where they're going…it's also about what the mirror looks like. So…what the mirror looks like is based on how I look in clothes. So, I often spend time, whether it's a female or a male and talk about, “What's your favorite pair of jeans? What size are you in and what size do you think you might like to be in?” And so we'll work from that versus, again, a number on the scale. But I work mostly on their health parameters. And that helps a lot.

Pennings: Much of that weight loss is visceral fat weight loss, which is going to reduce that waist circumference. So you'll see clothes fitting better, but also can have a disproportional benefit on health improvement with weight loss.

Golden: Yes, and I think the other thing it can do is, they can see it easier, so I also use waist circumference. And of course, in my obesity practice I have a body composition scale, so I do follow their fat percentage. But I think, also, the other piece is that I have them fairly early in their treatment start anaerobic activity. Because if I can keep their muscle mass high but also get toning they will start to see a difference in how clothes fit and what that waist circumference measurement looks like much earlier than they would have thought by looking at a number on the scale.

Pennings: So one of the other biggest myths that you didn't talk about in your talk that I find in my patients is that, with respect to obesity, once you lose weight, the job is done. And reality, once the desired weight is achieved, the hard part is really just beginning. I find weight maintenance is the hardest part. [crosstalk] What are your strategies for working with patients to maintain their weight?

Golden: You know my strategy starts pretty much within the second or third visit with them. And the reason it starts that early is that, I've yet to have a patient that has come to me that hasn't done 7 or 8 very successful weight loss attempts. It's just that the weight went out and found five or ten friends and came back. And that was my own experience for years before I understood the pathophysiology of obesity. So it's another place that I can come back to get them away from willpower as their basis for understanding what's happening to them. And I again go back to the brain. I talk to them about as they've lost weight, what their brain does, because part of the disease of obesity. The reason it's a chronic relapsing disease is because the hypothalamus sees that fat mass that I had before as what it wants me to keep. So it defends that. And so I get an increase in ghrelin. I am hungry after I lose weight. That is so impactful for patients when they're like, “I thought it was just because I didn't have any willpower.” No, it's because there's biology underneath what we now know and call metabolic adaptation. And again, it's another powerful way, (a) to explain the disease, but (b) to explain to patients why it's a chronic disease and why when they get to their goal, they still have to continue to get treatment.

Pennings: Right, so why we need to continue long term treatment with anti-obesity medications and not just stop them once they get to their target weight? I think that really is an important thing for people to understand. But also from a mental side, patients are not getting the feedback that they're getting when they're losing weight. They're not getting the feedback and the scale going down. They're not getting feedback from others' comments. And that can be a struggle for people. I describe it like having a job where everything you do right is expected and anything you do wrong is harshly criticized. And that's how people treat themselves very often. That the weight goes up, you know there's hell to pay. If it stays where it was, well, that's what it's supposed to be [crosstalk].

Golden: Yes, that judge and jury in their brain [crosstalk] Yep, yep that judge and jury in their brain doesn't say “Oh, good job for keeping your weight where it is.” Yeah, there's no kudos for weight maintenance.

Pennings: Right, so I have them track the number of days they stay in their target range. And that way, each day it's improving, each day you've got another day, the metric that can reinforce the behavior. I find that to be helpful, to help people stay on course and not get discouraged because their weight hasn't changed.

Golden: Absolutely. The other thing that I do is…my patients all have a metric where they know they have to get back in sooner if it's before their three-month follow up visit for their chronic care visit. And unfortunately, the only thing I've come up with and maybe you have something better than I do, is a weight regain of 5 pounds. If they hit 5 pounds, then before that three-month mark, they need to get an appointment earlier so that we don't get up to the 10-pound, 15-pound mark of weight regain. I want them to see me sooner so that we can figure out what's going on. I'd love it if I have something besides a number on a scale, since I've spent all this time with them telling them not to pay any attention, that the number on the scale isn't the most important piece and now I'm saying, “Well, maybe during maintenance it's pretty important.” If you have something that you do that is a different way to approach that, I would love to hear it, but I think that that's an important part for our physician, NP, and PA colleagues to keep in mind is, what is that key going to be? You tell patients to get back in sooner.

Pennings: And I think a 5-pound metric is a good one. I use that as well. But also if they're, say an emotional eater and they have an emotional crisis in their life and they see themselves going down a path of eating in an unhealthy way, then they need to come back in sooner. So, if they're struggling, it doesn't have to be just in their weight, but if they're mentally struggling, staying on program that's another reason to come in sooner.

Golden: That's a great one.

Pennings: Lastly, when discussing obesity treatment with patients, what is your favorite bit of advice?

Golden: Hmm, I think my favorite bit of advice is if they hear the voice in their head saying, “That's good food or bad food,” or “I was good or bad today,” that they're back to thinking of it in a willpower way; that they've lost the perspective of the chronicity of the disease. And that we need to revisit that. I need to know that they're hearing that judge and jury again, because that's bias that they've got. That's an internal bias. When they start to hear their words, whether they hear them come out of their mouth or they just hear it in their head, I want to know because we need to talk again, we need to reframe those words. And to me, that's probably the thing that I feel the strongest about for my patients is I have to help them get past this internal bias that's been so much a part of their life for so long.

Pennings: And I talk about that a lot as well, because good and bad is judgmental. It's emotional and it's ambiguous. Is a cookie good? Is it bad? Well, it tastes good, but it's bad for you. If you're good you reward yourself with a cookie, but then you're bad because you ate it. So that ambiguity creates a lot of confusion with patients. I always encourage my patients to think of food as healthy or unhealthy. It's so either going to make your health better or it's going to make your health worse. And then that ambiguity goes away. Then it's clear that a cookie is unhealthy. If your goal is to be healthy, which I think we all have a fundamental goal to be healthy, then your decision to not eat that cookies in line with your goals and trying to align those components.

Well, thank you. This is a very interesting conversation and enjoy talking with you today.

Golden: I hope that people take a nugget away from this podcast. This was great fun.

Pennings: I hope so too. You can find Dr Golden's presentation on the OMA Academy. It is The Top 10 Obesity Myths. Thanks again, Angie.

Golden: Thanks for having me, Nick. Bye.

Outro: [outro music] Thank you for listening to this episode of Obesity: A Disease. For more information about obesity medicine podcasts, and other valuable resources from the clinical leaders in obesity medicine, please visit www.obesitymedicine.org\podcast. If you enjoyed this episode, and want to listen regularly, head over to iTunes, where you can subscribe, rate, and leave us a much-appreciated review. The views expressed in this episode are those of the host and guests and do not necessarily represent the opinions, beliefs, or policies of the Obesity Medicine Association or its members. Please join us again for our next episode of Obesity: A Disease.

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Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

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